Form DR 0811 Fillable Catastrophic Health Insurance -- Employee
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

*130811==19999* above listed employer does not offer to provide me with any other form of health insurance Catastrophic Health Insurance COLORADO DEPARTMENT OF REVENUE Date (MM/DD/YY) Denver CO 80261 0005 DR 0811 (08/30/13) Employees Election Regarding Employee's Last Name employees under the provisions of 10 16 116 C R S I further certify that I reside in the State of Colorado and that the Employer's Address Employer's Name First Name I hereby certify that I am an employee of the above listed employer who has offered catastrophic health insurance to I hereby elect to have this catastrophic health insurance withheld from my wages by my employer on a Colorado pretax basis Middle Initial Signature State This election will continue in effect until canceled by myself by my employer or by the insurance carrier or until I cease to be employed by this employer